Evaluation and Treatment of Selected Sacral Somatic Dysfunctions

Home , Axis (anatomy), Ilium (bone), Ischium

Using Direct and HVLA Techniques including Counterstrain and Muscle Energy

AND Counterstrain Treatment of the Pelvis and Sacrum

F. P. Wedel, D.O. Associate Adjunct Professor in Osteopathic Principles and Practice A.T. Still University School of Osteopathic Medicine in Arizona, and private practice in Family Medicine in Tucson, Arizona Learning Objectives

HOURS 1 AND 2

Review the following diagnostic and treatment techniques related to sacral torsion

Lumbosacral spring test Sacral palpation Seated flexion test

HOURS 3 AND 4

Counterstrain treatments of various low back pathologies Sacral Techniques Covered :

1. Prone, direct, muscle energy, for sacral rotation on both same and opposite axes 2. HVLA treatment for sacral rotation on both same and opposite axes 3. Counterstain treatment of sacral tender points and of sacral torsion

Counterstrain

Multifidi and Rotatores : UP5L Gluteii – maximus: HFO-SI, HI, P 3L- P 4L ,medius, minimus Piriformis Background and Basis The 4 Osteopathic Tenets (Principles)

1. The body is a unit; the person is a unit of body, mind, and spirit. 2. Structure and function are reciprocally inter-related. 3. The body is capable of self- regulation, self-healing, and health maintenance. 4. Rational treatment is based upon an understanding of these basic principles. Somatic Dysfunction - Defined • “Impaired or altered function of related components of the somatic (body framework) system:

• Skeletal, arthrodial, and myofascial structures,

• And…

• Related vascular, lymphatic, and neural elements” Treatment Options for Somatic Dysfunctions All somatic dysfunctions have a restrictive barrier which are considered “pathologic” This restriction inhibits movement in one direction which causes asymmetry within the joint: The goal of osteopathic treament is to eliminate the restrictive barrier thus restoring symmetry…. Somatic Dysfunction: CHARACTERISTICS “The acronym TART is used to remember the abnormal changes that accompany somatic dysfunction. (Tenderness by itself is not always an indication of somatic dysfunction):

•Tissue texture changes •Asymmetry •Restricted range of motion •Tenderness Kimberly Manual, chapter 3 Treatment Methodologies Indirect – movement away from the barrier and more functional than structural Cranial-sacral Counterstrain Balanced ligamentous tension (BLT) Facilitated Positional Release Direct – engagement of the restrictive barrier and movement through it and to it by using the body part as a lever Muscle Energy and MFR HVLA Chapman’s and Lymphatics SACRAL STRUCTURE,LIGAMENTS AND MUSCLES THE SACRUM Means “sacred” because of its density it is the last bone to decay and because it protects the reproductive system

Forces on the sacrum

Angle of the sacroiliac joint “wedges” the sacrum in an anterior direction Prevents posterior movement

Dorsal (posterior) sacroiliac ligaments much stronger than anterior sacroiliac ligaments

Purpose: counteract significant pelvic forces pushing apex posteriorly. Major Pelvic Ligaments

Iliolumbar from ilia to 5 th lumbar vertebrae Sacrospinous Sacrum to spine of the ischium Sacrotuberous Sacrum to ischial tuberosity Sacroiliac Ligament Covers much of the sacroiliac joint, ant & post Iliolumbar ligaments

Stabilizes the 5th (4th) Lumbar vertebrae to the ilia Sacrotuberous Sacrospinous ligament ligament Iliolumbar lig

Sacrospinous Sacrotuberous Ligament

Runs from lower sacral tubercles to ischial tuberosity Gluteus maximus attachment Tendon of the biceps femoris attachment Connects with fascia of the pelvis from sacrum to ischial tuberosity stabilizes anterior motion Both Sacrospinous & Sacrotuberous stabilize to prevent posterior - superior rotation of the sacral apex around a transverse axis Sacroiliac Ligament

Sacroiliac actually three ligaments Anterior or ventral sacroiliac from 3rd sacral segment to lateral preauricular sulcus interosseous sacroiliac massive bond between the upper parts of the joint dorsal sacroiliac Partly covers the interosseous, from lateral sacral crest to PSIS and internal iliac crest. Ventral/Anterior Sacroiliac interosseous

Posterior sacroiliac

Pelvic muscle attachments from above. Attach to Sacrum Erector Spinae Iliocostalis Longissimus Spinalis Multifidus

Attach to Innominates Obliques (internal, external, transverse) Quadratus Lumborum

Posterior Muscles Erector Spinae (sacrospinalis and iliocostalis) SACRAL ANATOMICAL AXES

Transverse axis

Superior : the cranial&primary respiratory mechanism creates motion around this axis Middle : sacral base anterior and posterior (FB/BB) occur around this axis Inferior : the innominates rotate around this axis SACRAL MOTION

Respiratory motion: inhalation sacral base moves posteriorly (counter-nutates) Respiratory exhalation: sacral base moves anteriorly (nutates)

Inherent (craniosacral)motion: ***Craniosacral flexion-base rotates posteriorly (counter- nutates) Craniosacral extension-base rotates anteriorly (nutates)

SACRAL PHYSIOLOGIC AXES

• Oblique : both left and right oblique axes are named for the superior pole • Sagittal : includes both mid-sagittal and an infinite number of parasagittal axes • Horizontal : functional axis of sacral flexion/extension occur around this axis (analogous to the middle transverse axis above) (footnote on functional anatomy) Why are the Oblique Axes so significant?

They are the Axes of Walking . The walking cycle as it applies to our discussion 1. From a standing ( neutral ) position, when you take a step forward, your weight is shifted onto one lower extremity. 2. This induces spinal column SB to the weight bearing side, and pins the upper pole of the sacrum on the side of the SB. 3. As the free lower extremity swings forward, it carries the free pole of the sacrum anterior, creating rotation of the sacrum about the Oblique Axis, towards the weight bearing extremity.

Ex.: RL on LOA RR on ROA

Bottom Line: You form Oblique Axes with every step you take! The other aspect of the walking cycle is the movement of the torso. 1. From a standing ( neutra l) position, as you step forward, note how your body compensates. What does your torso do? 2. Answer: Rotates towards the moving lower extremity (ie.: away from the weight bearing lower extremity).

Bottom Line: Your spine (most notably Lumbar spine) rotates in the opposite direction of the sacrum in a neutral moving situation. TESTS To make a Sacral Diagnosis you will need to know the following:

Static (Pure) Landmarks Sacral base - Ant/ Post ILA -Ant/Post ASIS & PSIS -Sup./Inf. Pubes -Sup./Inf & Ant./Post Mixed Landmarks Sacral Sulcus - Deep/Shallow STL -Tight/ Loose/ Equal Motion Testing Spring test L5 Sacrum •Record Positive Right, Positive Left, or Negative Test Spring Test

1. Find sacral base 2. Place heel of hand over Lumbosacral junction 3. Spring in an Anterior motion 4. Results: a. Positive test = If there is NO springing allowed = Non-neutral condition (AKA Backward torsion ) b. Negative test = If there is springing allowed = Neutral condition. Prone Landmarks Sacral Base Judge whether the tip of the thumb is more anterior on one side than the tip of the thumb on the other side. Can also bring index fingers over onto sacral base and take measurement on the lateralized side. Record which base is anterior. Sacral Sulcus Depth Palpable groove just medial to PSIS. Space between sacral spines and lateral sacral crest. Place thumbs in inferior border of PSIS. Move ½-1” up and medial to PSIS. Push thumb tips on sacral base. Pads of thumbs are on ilium and tips on sacral base. Measure the depth of each sacral sulcus relative to opposite sulcus? Record even, deep, or shallow, comparing one side to the other. Both sides may be shallow or deep as well. Inferior Lateral Angle 1. Place flat of hand over sacrum near its caudal end and identify the coccyx. 2. Thumbs approximately 1” apart. Place thumbs in gluteal area about 1” caudal and on each side of coccyx. 3. Push thumbs cephalad until pads rest on inferior margin of ILA. Take a reading on the lateralized side: Inferior or superior? Possibly even? 4. Move thumbs approximately 1” cephalad from the inferior margin of the ILAs and place the pads of the thumbs over the posterior surface of the ILAs near the apex of the sacrum. 5. Use moderate equal pressure & judge if one side is more anterior or posterior than the other one or are they equal? Record on the lateralized side. 1. Place thumbs on the inferior margin of ILA. 2. Move thumbs inferiorly and laterally from the ILA bilaterally, palpating for the sacrotuberous ligament. 3. Ligament will be found between the ILA and Sacrotuberous the ischial tuberosity on each side. Ligament 4. Press thumbs anteriorly, superiorly, and 45-50 degrees laterally to check the tension on the sacrotuberous ligaments. 5. Are they equal in tension or is one tighter or looser than the other? Note which side is looser and which is tighter, relative to the other side. L5 Locate L5 transverse processes, bilaterally Place thumbs over L5 transverse processes, bilaterally Note relative positions of L5 transverse processes bilaterally Which is anterior? Which is posterior? What is the preference of motion at L5 for Rotation?

Record the Rotation of L5, Right, Left, or No Rotation

L5 rotates to the opposite side of sacrum and side bends to same side as the sacral axis motion Motion Tests for Sacral Diagnosis

ASIS Compression Test Have the patient lie supine. The patient is then asked to raise his/her bottom up off the table and then set it back down again. Doctor Stands with head and shoulders centered over the patient. Contact the ASIS Stabilize one ASIS while applying pressure at a 45 degree angle to the other ASIS Positive test - restricted movement of the Sacroiliac joint -> rock like motion Negative test - a sense of give or resilience => bounce or spring like motion DIAGNOSIS AND TREATMENT Of SACRAL TORSIONS

Sacral Dysfunction Assessment Are ILA’s Symmetric Superior/Inferior? No Yes

Non - physiologic: Physiologic: Unilateral Sacral Shear Oblique Axis: (Unilateral Sacral Flexion Sacral Torsions And Extensions)

Is the Sacral Base Symmetric Anterior /Posterior? No Yes Sacral Margin Posterior Sacral Base Posterior Sacral Base Anterior Upslipped Innominate

Neutral Sacrum FRYETTE’S LAWS

Law I : When the spine is in neutral, sidebending to one side will be accompanied by horizontal rotation to the opposite side . In type I somatic dysfunction, this law can be seen when more than one vertebrae are out of alignment and cannot be returned to neutral by flexion or extension. The involved group of vertebrae demonstrates a coupled relationship between side bending and rotation. When the spine is neutral, side bending forces are applied to a group of typical vertebrae and the entire group will rotate toward the opposite side: the side of produced convexity. Extreme type I dysfunction is similar to scoliosis.

Law II : When the spine is flexed or extended (non-neutral), sidebending to one side will be accompanied by rotation to the same side. In type II somatic dysfunction of the spine, this law can be seen when only one vertebrae is out of place and becomes much worse on flexion or extension. There will be rotation and sidebending in the same direction when this dysfunction is present

Law III : When motion is introduced in one plane it will modify (reduce) motion in the other two planes. Type III sums up the other two laws by stating dysfunction in one plane will negatively affect all other planes of motion Lumbosacral Mechanics and Torsions

Example L rotation on LOA

Lumbar spine neutral: S L RR (note in all torsions, L5 will rotate opposite of sacrum) N.B. this example is type 1- which go with Forward torsions as type II go with backward torsions Requires normal lordosis SL RR A Occurs when (R) sacral base rotates anterior (“forward”) and does not rotate back (feels “springy”) L on L left ILA posterior, & inferior OA P (i.e., taking a step forward on r leg) Sacral Motion In Neutral (type I) mechanics: the sacral base moves Anteriorly and rotates opposite to the rotation of L5 ;

Its axis motion is the SAME as the SB side of L5 so :

Example: L5 RrSl causes a L on LOA, ( L on L) sacral torsion the R edge is rotated L and anterior while the axis is left so it = to the SB side of L5 Sacral Motion

In Non-Neutral (type 2) mechanics, the sacral base rotates backwards . It is still opposite to the L5 rotation side and Its axis is the same as the L5 SB side

Example: L5 RlSl causes a R on LOA, the right sacral base moves Posteriorly while its axis side is Left and oblique Sacral Torsion Rules

A sacral torsion requires a deep sulcus and a posterior and inferior ILA to be on opposite sides

A deep right sulcus must have an posterior and inferior ILA on the Left by the above definition Sacral Sulcus Depth Palpable groove just medial to PSIS. Space between sacral spines and lateral sacral crest. Place thumbs in inferior border of PSIS. Move ½-1” up and medial to PSIS. Push thumb tips on sacral base. Pads of thumbs are on ilium and tips on sacral base. Measure the depth of each sacral sulcus relative to opposite sulcus? Record even, deep, or shallow, comparing one side to the other. Both sides may be shallow or deep as well. o Sacral Torsion Rules

Name of lesion :

Is for rotation and axis sides: R on R = right rotation on a right axis

R on L = right rotation on left axis Sacral Torsion Rules

Rotation side = the 1st of the 2 letters: L on L, or L on R, R on R, or R on L

The 1st Letter

Is also the posterior or backward edge of the sacral base

Is the Short leg side

Is the side of the posterior/ inferior ILA Sacral Torsion Rules

The second letter ( R on R) refers to the Axis side of the sacrum that is in play

Is the same as the side bent side of L5 Sacral Torsion Rules

Seated flexion test is + on the side of the dysfunctional edge of the sacral base that is rotated either R or L and is either forward or backward

The seated flexion test is the hallmark objective exam to determine your torsion diagnosis side and thus what edge to treat Sacral Torsion Rules

L5 will be Convex to deep sulcus which = anterior edge

Long leg on deep sulcus = anterior edge

Forward lesions no + spring ; back ward lesions + spring FORWARD TORSIONS

Neutral - Left Oblique Axis Findings

Name : L on LOA, R L on LOA,

L5: SLRR Landmarks – Static : Sacral Base: L posterior A + Sacral Sulcus: L shallow ILA: L Post/ Inf. STL: L Tight Motion Testing : ↓ Spring: - (neg) P +/-

L5: SLRR Sacral Base L - R + ILA: L +/-R +/- Left Right Midline Neutral - Right Oblique Axis Findings:

Name : R on ROA, R R on ROA,

Landmarks – Static: Sacral Base: R posterior A+ Sacral Sulcus: R shallow ILA: R Post/Inf. STL: R tight ↓ Motion Testing : P +/- Spring: - (neg) L5: SRRL Sacral Base: L + R - Left Right ILA: L +/- R +/- Midline

Right Forward Torsion

RR on ROA Palpatory Experience We can induce these Neutral diagnoses using the mechanics of the sacrum and spine… SB L --> L on LOA

A+

P↓+/-

Forward Sacral Torsion ME (a right on right sacral torsion)

1. Axis side down; chest on the table

2. Monitor at the lumbo-sacral junction

3. Flex the knees and hips until motion is felt at the lumbosacral junction

4. Support legs/knees with thigh or pillow

5. Apply pressure downward on lower legs/ankles

6. Ask patient to try to raise feet towards the ceiling while you resist

7. Rest

8. Re-engage barrier by repositioning ankles downward Relative contra-indications-acute sacroiliac sprain, acute sacrum fracture, severe knee 9. Repeat 6, 7, 8 arthritis, deep venous thrombosis, or premature labor 10. Recheck HVLA FOR ANTERIOR SACRUM

Anterior Sacrum Leg Pull – HVLA ( SDOFM 118 – 9.6 ) Associated with forward sacral torsions, eg. L on L 1. Patient supine, physician stands at foot of table 2. Grasp patient’s right ankle just Above malleoli with both hands. 3. Instruct patient to relax all muscles in low back and leg 4. Internally rotate leg to accumulate forces at Right Sacroiliac Joint (Gaps the SI joint) 5. Keep leg and thigh at level of table 6. Apply quick pull on leg, carrying right innominate anteriorly to meet sacrum (correcting the somatic dysfunction) Contraindicated in knee instability 7. Recheck Posterior Sacrum Leg Pull – HVLA ( SDOFM 119 – 9.7 ) Eg. Right Posterior Sacrum = Sacrum rotated Right on the Left Oblique Axis. 1. Patient supine, physician stands at foot of table 2. Grasp patient’s right ankle just Above malleoli with both hands. 3. Instruct patient to relax all muscles in low back and leg 4. Internally rotate leg to accumulate forces at Right Sacroiliac Joint (Gaps the SI joint) 5. Keep the knee extended and flex hip until tension is felt on hamstrings 6. Apply final corrective force (quick pull on leg), carrying right innominate posteriorly to meet sacrum. Contraindicated in knee instability 7. Recheck POSTERIOR SACRAL

TORSIONS

Non-Neutral: Left Oblique Axis Findings (right on left sacral torsion)

Name : R on LOA, R R on LOA, Landmarks – Static : Sacral Base: L Anterior S Sacral Sulcus: L Deep L5: R L L ILA: L Ant/ Sup P+/- STL: L Loose Motion Testing : Spring: + (positive) L5: R S L L ↑↑↑ Sacral Base L - R +/- A + ILA: L + R +/- Left Right Midline Non-Neutral: Right Oblique Axis Findings (left on right sacral torsion) Name : L on ROA, R L on ROA,

Landmarks : P+/- Sacral Base: R Anterior Sacral Sulcus: R Deep ILA: R Ant./Sup. A↑↑↑+ STL: R loose Motion Testing : Spring: + Left Right L5: RRSR Midline Sacral Base: L +/- R - ILA: L +/- R + Right Backward Torsion

RL on ROA Palpatory Experience We can induce these Non-Neutral diagnoses using the mechanics of

the sacrum and spine... SB L-> R on LOA

P+/-

A↑↑↑+ Backward Sacral Torsion Muscle Energy ( left on right torsion)

1. Have the patient lie on the table axis side down

2. Monitor at the lumbosacral junction

3. Rotate the upper torso posteriorly until motion is felt at the lumbosacral junction

4. Hold the position of torso rotation

5. Flex the top leg until motion is felt at the lumbosacral junction; bend the knee and adduct the hip until motion is felt

6. Ask the patient to push their knee up towards the ceiling while you resist

7. Rest

8. Re-engage the barrier by adducting the knee/hip until motion is felt at the lumbosacral junction Relative contraindications: acute sacroiliac sprain, acute sacrum 9. Repeat 6, 7, 8 fracture, severe hip arthritis, deep venous thrombosis, or premature 10. Recheck labor HVLA FOR POSTERIOR SACRUM

ORIGINAL COUNTERSTRAIN SACRAL TENDERPOINTS

Sacrum

• The tender points are probably in the areachment of atta of the • multifidis, spinalis, longissimus, iliocostaliscles & mus overlying fascia COUNTERSTRAIN FOR SACRAL TORSION (not the same as counterstrain for the sacrum)

Paper published by Ramirez in JAOA Vol 91 No 3 March 1991 described the following: Both anterior and backward sacral torsions were treated by: 1)noting the side of the tender sacral foramina – (will be the same as the axis side of the torsion) 2)sitting on opposite side of the tender points and abducting prone patient’s leg 30 degrees off table and flexing hip to rest on your thigh 3) pushing anteriorly on ipsilateral PSIS with operator’s forearm for 90 seconds SOURCES AND RESOURCES KIMBERLY MANUAL-2006 EDITION POCKET MANUAL OF OMT-2ND EDITION PRINCIPLES OF MANUAL MEDICINE-GREENMAN OMT REVIEW-SAVARESE-3RD EDITION LECTURES FROM OMM FACULTY – A.T.STILL UNIVERSITY-PHOENIX AZ- WITH PERMISSION LECTURES FROM DR.HARMON MYERS JAOA Vol 91 No 3 March 1991 THANK YOU

SACRAL SHEARS ILAs are inferior and posterior on same side of deep sulcus – which distinguishes this from a torsion Produced when the sacrum shifts forward within the sacroiliac joint.

Two Types: Unilateral Sacral Flexion Unilateral Sacral Extension Sx: Chronic low back pain.

Naming the Shear

The shear is named for the side of the inferior ILA.. The sulcus is deep on same side- (which distinguishes this from a torsion) The seated flexion positive side will tell you how to interpret whether it is a unilateral flexion or extension, i.e.,sulcus deep and ILA on R with R seated flexion + = R unilateral Flexion; L unilateral extension if seated is + L with the same findings of: deep sulcus R and ILA post/inf R

Springing Respiratory Force Left Unilateral Sacral Flexion A

Monitor at PSIS

Abduct and internally rotate LE until motion is felt.

Maintain that position by leaning of the patient’s femur/leg Springing Respiratory Force Left Unilateral Sacral Flexion B

1. Contact left ILA and apply superior and anterior pressure

2. Have the patient take a deep breathe in and hold (encourages sacral base to move posteriorly)

3. Spring anteriorly and superiorly while patient is holding breath

4. Exhale while physician maintains gain in position

5. Repeat steps 2, 3, 4

6. Recheck

SOURCES AND RESOURCES KIMBERLY MANUAL-2006 EDITION POCKET MANUAL OF OMT-2ND EDITION PRINCIPLES OF MANUAL MEDICINE-GREENMAN OMT REVIEW-SAVARESE-3RD EDITION LECTURES FROM OMM FACULTY – A.T.STILL UNIVERSITY-PHOENIX AZ- WITH PERMISSION LECTURES FROM DR.HARMON MYERS THANK YOU Upslip innominate(pubic shear) UPSLIP INNOMINATE Diagnose: L iliac crest superior L ischial tuberosity is superior L medial malleolus is superior L base is anterior so sulcus may be Deep L ILA may be posterior but ILAs are = Seated flexion + L ASIS compression is + L Motion restricted at L base and ILA Tender at S/I joint Upslip treatment

Superior Iliac/Pubic Shear

Place pressure pad caudad to ipsilateral ILA to help restrict caudad motion of the sacrum

Abduct and internally rotate to gap the ipsilateral SI joint

Have the patient take a deep breath and hold (encourages sacral base to move posteriorly)

Tug along the long axis of the lower extremity

Release

Recheck Muscle Energy Superior Pubic Shear

1. Patient supine with dysfunctional side towards the edge of the table

2. Monitor opposite ASIS

3. Extend hip until motion is felt at the monitoring hand

4. Ask the patient to pull knee up while you resist

5. Relax

6. Re-engage extension

7. Repeat 4, 5, 6

8. Recheck Muscle Energy Inferior Pubic Shear

1. Monitor ipsilateral ASIS

2. Flex and abduct the hip

3. Contact ischial tuberosity

4. Posteriorly rotate the hip with pressure on the ASIS, ischial tuberosity, and knee

5. Have the patient attempt to straighten the leg while you resist

6. Relax

7. Re-engage rotation Posterior Iliac rotation carries pubic ramus superiorly 8. Repeat 5, 6, 7

9. Recheck Sacral Somatic Dysfunction (AKA Sacroiliac Dysfunction)

Physiologic : Non - physiologic : Dysfunction that occurs Dysfunction that does not around a Physiologic occur around an axis. Axis Usually caused by trauma .

1. Vertical 1. Upslipped Innominate 2. Transverse 2. Unilateral Sacral 3. Oblique: Neutral and Shear (Unilateral Non-Neutral Sacral Flexion) Piriformis Movement

The only Vertical Axis Diagnosis is…

Name : Sacral Margin Posterior

For Left Sacral Margin Posterior: Landmarks : P – Sacral Base: L Posterior Shallow Sacral Sulcus: L Shallow ILA: L Posterior STL: L Tight Motion : P - Sacral Base: L – ILA: L – Sacral Margin Posterior cont...

For right sacral margin posterior: Landmarks: Sacral Base: R posterior Sacral Sulcus: R shallow ILA: R posterior P – Shallow STL: R tight Motion: Sacral Base: R - P – ILA: R -

Right Sacral Margin Posterior Sacral Margin Posterior: (ILA’s are level superiorly/inferiorly)

On the posterior side: Entire sacral margin is posterior Base is posterior ILA is posterior Sulcus is shallow Sacrotuberous ligament is tight Anterior springing at the superior and inferior poles is restricted Sacral Margin Posterior can occur on either side of a Vertical axis, but it is always named for the posterior side!

P – P – Shallow Shallow

P – P –

Left Sacral Margin Posterior Right Sacral Margin Posterior HVLA Posterior Sacral Margin

Stand on side opposite the posterior margin

Sidebend the patient away from you

Stabilize the ASIS on the posterior margin side

Have patient clasp hands behind neck

Place cephalad arm through the space created by the patient’s arm and rest on sternum

Rotate the patient towards you (spine and sacrum) until tension is felt at the stabilizing ASIS

HVLA thrust is applied posteriorly through the ASIS

Recheck

SACRAL DIAGNOSIS Diagnosis Seated Flexion Sacral ILA levelness L5 Spring LS Flexion Test Base/Sulci Rot Test Asymmtry

Left on left Right Anterior right Posterior left Right Negative Decreased

Left on Right Left Anterior right Posterior left Right Positive Increased Right on right Left Anterior left Posterior Right Left Negative Decreased

Right on Left Right Anterior Left Posterior Right Left Positive Increased

Left Unilat Flex Left Anterior Left Posterior Left - Negative Decreased

Left Unilat Ext Left Anterior Right Posterior Right - Positive Increased

Right Unilat Right Anterior Right Posterior right - Negative Decreased Flex Right Unilat Ext Right Anterior Right Posterior left - Positive Increased

Ant Margin - R Right Anterior Right Anterior Right Left Negative Decreased

Ant Margin – L Left Anterior Left Anterior Left Right Negative Decreased

Post Margin – Right Shallow R Posterior Right Right Positive Increased R Post Margin – L Left Shallow L Posterior Left Left Positive Increased

Bilateral Flexion N/A Deep Bilateral Shallow Bilateral - Negative N/A

Bilateral Extnsn N/A Shallow Deep Bilateral - Positive N/A Bilateral

SacralSacral AxesAxes Multiple axes of motion: Transverse (3) Superior S1 Middle S2 Inferior S3 Vertical (sagittal) A/P Oblique (2) Left Right

Supine, indirect, respiratory cooperation, for bilateral flexion - 4521.11C

Sacral Base Anterior (several terms describing the same motion)

Sagittal Plane-Middle Transverse Axis Bilateral Sacral Flexion Kimberly manual 2006, p. 193 (4521.11A-E) (different than the sacral “flexion & extension” in the Magoun-type cranial field model) Nutation From the Latin “nutare”- to nod Nutated Sacrum Anterior Nutation Sacral Base Anterior (Bilateral Sacral Flexion)

Inferolateral angles level Sulci deep bilaterally Sacral base anterior bilaterally Sacrotuberous ligaments tight bilaterally Base anterior springing present Apex anterior springing restricted Look for “discontinuity” at the lumbo-sacral junction Sacral Base Anterior : Base bilat. anterior on the middle transverse axis Name : Sacral Base Anterior, Or bilat. Sacral Flexion, Or Nutation

Landmarks : Sacral Base: Bilat. Anterior Sacral Sulcus: Bilat. Deep A + A+ Deep Deep ILA: Bilat. Posterior STL: Bilat. Tight Motion : Sacral Base: Bilat. + ILA: Bilat. – P - P-

Muscle Energy Bilateral Sacral Flexion

Physician contacts paraspinal muscles lateral to L5

Flex patient until motion is localized at lumbosacral junction

Have patient attempt to gently straighten legs

Resist

Rest

Re-engage flexion and repeat Sacral Base Posterior

Sagittal Plane-Middle Transverse Axis Bilateral Sacral Extension Kimberly manual 2006, p. 197 (4522.11A-C) (different than sacral “flexion & extension” in the Magoun-type cranial field model) Counter Nutation Posterior Nutation Sacral Base Posterior (Bilateral Sacral Extension ) Inferolateral angles level Sulci shallow bilaterally Sacral base posterior bilaterally Sacrotuberous ligaments “relaxed” bilaterally Apex anterior springing present Base anterior springing restricted Sacral Base Posterior Base bilat. posterior on the middle transverse axis

Name : Sacral Base Posterior, Bilat. sacral extension ,or Counternutation

Landmarks : Sacral Base: Bilat. Posterior P - P- Sacral Sulcus: Bilat. Shallow Shallow Shallow ILA: Bilat. Anterior STL: Bilat. Loose Motion : A + A+ Sacral Base: Bilat. – ILA: Bilat. +

SACRAL MECHANICS

Physiologic diagnoses of the sacrum occur in neutral and non-neutral mechanics: Neutral Mechanics a.k.a.

Left rotation on a Left Oblique Axis or Forward Torsion Sacral Nutation or

(all three are equivalent terms!!)

In neutral mechanics, the sacrum rotates in the same direction as the oblique axis (left rotation on a left oblique axis) Non-neutral Mechanics a.k.a.

Right rotation on a Left Oblique Axis or Backward Torsion or Sacral Counter-Nutation

(all three are equivalent terms!!) In non-neutral mechanics, the sacrum rotates in the opposite direction of the oblique axis (right rotation on a left oblique axis) FRYETTE’S LAWS

Law I : When the spine is in neutral, sidebending to one side will be accompanied by horizontal rotation to the opposite side . In type I somatic dysfunction this law can be seen when more than one vertebrae are out of alignment and cannot be returned to neutral by flexion or extension. The involved group of vertebrae demonstrates a coupled relationship between side bending and rotation. When the spine is neutral, side bending forces are applied to a group of typical vertebrae and the entire group will rotate toward the opposite side: the side of produced convexity [2] Extreme type I dysfunction is similar to scoliosis . Law II : When the spine is flexed or extended (non-neutral), sidebending to one side will be accompanied by rotation to the same side. In type II somatic dysfunction of the spine, this law can be seen when only one vertebrae is out of place and becomes much worse on flexion or extension. There will be rotation and sidebending in the same direction when this dysfunction is present [3] . Law III : When motion is introduced in one plane it will modify (reduce) motion in the other two planes. [4] Type III sums up the other two laws by stating dysfunction in one plane will negatively affect all other planes of motion